What is risk?

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Chapter 2 What is risk?

It must be understood that risk cannot be eliminated entirely. To do so would be to move from risk management to certainty management, which is not possible within clinical practice.¹

Risk is in everything that people do. Driving to work entails taking risk although often this is not consciously considered. Choosing a car or a house can be a very risky business. Buying a house requires care and assessment of all sorts of possibilities before the cheque is signed.

If there were no potential benefits to be had, people would never take any risks. For example, everyone takes risks getting to work each day and yet if they didn’t take those risks, nothing would ever get done.

There will always be a degree of uncertainty about what might happen when risks are taken. For those risks that are taken every day, the likelihood of something going wrong is known to be quite low so anxiety is low. However, when it is a new risk or if the possible outcome is very severe, anxiety levels can be substantially higher.

The opposite of risk — certainty or complete safety — is something which can never be achieved in a mental health setting so clinicians will always find themselves needing to work alongside patients with a certain degree of risk and its accompanying anxiety.

For risks such as crossing the road or driving a car along the motorway, there is no need to think about how to manage the situation effectively as it has been done a thousand times before. Managing risk in a mental health setting is no different. It is primarily an exercise in decision-making. The task is to try and prevent adverse outcomes whilst maximising the likelihood of a good outcome (risks versus benefits). The process of decision-making can vary from an intuitive decision made on the run using cognitive shortcuts (heuristics; see glossary) to a deliberate, carefully considered plan made over several days or even weeks. There are advantages and disadvantages to each process which will be explored throughout the book. With regular practice, clinicians can learn to manage risky situations effectively and minimise the risk of adverse outcomes whilst continuing to treat and care for patients.

With a clear structure to risk management, decision-making can be documented in the notes and information shared with patients and other staff. There will be less need to rely on gut feelings and intuition. Staff will be less anxious about what they are doing and will have greater potential for flexibility.

With the increasing accountability expected today, it has become more necessary to ‘document our thinking for the record’.² Having a good structure simplifies this process substantially.

BOX 2.1 SUMMARY OF LEARNING POINTS

• If there were no potential benefits, clinicians would not need to take risks.

• Decision-making can be done quickly using cognitive shortcuts (heuristics) or be made more slowly in a deliberate and carefully weighed fashion.

• Having a clear structure to the assessment and management of risk makes practice transparent and improves communication.

Definition of risk

Dictionary definitions of risk vary, but commonly used definitions in mental health settings are:

Risk: the likelihood of an adverse event or outcome.

Risk: the possibility of incurring misfortune or loss.

Compare these definitions with the definition of chance:

Chance: the unknown and unpredictable element that causes an event to result in a certain way rather than another.

The word ‘chance’ is often confused with risk but it has a slightly different definition in which the outcome may be favourable.

There are three major components to any definition of risk:

2. outcome: it needs to be an adverse event

3. time: how imminent is the event?

The likelihood of an event can also be considered in terms of probability, possibility, prediction and so forth.

The special quality within the definition of risk as compared to chance is that risk focuses on adverse or undesirable outcomes. It is incorrect to speak of risk when talking about an outcome which is desired. People do not talk of the risk of winning the lottery; they talk about the chance or odds of winning. Clinicians do, however, talk about the risk of a patient committing suicide and other adverse outcomes. If staff become overly occupied with suicide, homicide and self-harm it becomes easy to lose sight of the possibility of positive outcomes such as the patient getting better, or having fewer thoughts of suicide and self-harm.

When the risk may occur is not usually considered in dictionary definitions of risk. It is important, however, within mental health work to consider the time period within which risk management is being considered. The likelihood of a patient committing suicide within the next 24 hours might be very high whereas the likelihood of the same patient committing suicide within the next 2 years might be quite slim or vice versa. Whenever risk is being managed, consideration needs to be given to the imminence of the risk.

Words may come to mind when someone says ‘risk’, such as:

danger, threat, possibility, prospect, disaster, speculation, uncertainty, hazard, peril, gamble, jeopardy, unsafe, perilous, dodgy, touch and go, bold, daring, high gain, and so on.

Risk in mental health settings used to be synonymous with the words danger or hazard which promoted defensive practice. With increasing understanding of risk factors, the link with these words is fading and a more structured approach to the management of risk is occurring.

What are the sorts of risks?

Within mental health settings, risk is usually thought of in terms of violence, suicide or self-harm. Most people then think of risk to the patient. In practice, however, risk is a part of every decision that is made about a patient’s treatment or care. If a list was drawn up of risks that existed in the workplace, it would be endless. Here are some of the risks which clinicians are involved with:

violence, death, litigation, complaints, coronial inquiries, verbal abuse, patients getting worse, burn out, sick leave, risk of relapse, insufficient resources, taking short cuts, side effects, needle stick injuries, overdose, medical complications, medication errors, social stigma, institutionalisation, stalking, intoxication, boundary problems, suicide, self-harm, and so on.

A simple method of categorising risk is set out in Table 2.1.

Table 2.1 Methods of categorising risk

Risks to self	Risk to others	Risk from others
• Suicide and self-harm. • Health: including alcohol and drug use, physical harm, and psychological harm. • Relapse of illness. • Quality of life: including dignity, social and financial status. • Self neglect.

• Violence: including emotional, sexual and physical violence.

• Intimidation/threats.

• Neglect/abuse of dependants.

• Stalking/harassment.

• Property damage: including arson.

• Public nuisance.

• Reckless behaviour: including driving.

• Harm to patients from others, especially children and elderly.

• Vulnerable patients; for example, patients with mania, dementia and borderline personality disorder (BPD) are especially at risk.

• Vulnerability: including exploitation, sexual abuse and violence from others.

• Domestic violence.

Risks to whom?

Once again, the immediate thought would be risks to patients. In practice, other patients may be at risk of neglect due to more attention being paid to one particular, difficult patient or patients may be at risk of imitating self-harming behaviour displayed by another patient on the ward. In some instances, patients and clinicians may be at risk of vicarious traumatisation (see glossary) if they see an unsettling incident on a ward.

Clinicians may be at risk of burnout, stress, complaints or boundary violations.

The mental health service may be at risk of complaints, inquiries, financial costs, the effect of staff taking excessive sick leave etc. In addition, the family or community may be at risk from patients who are violent or they may be vulnerable subsequent to a patient’s suicide.

What means might be used?

For violence, the history will need to include an exploration of whether the patient has a history of using weapons or whether the patient has access to weapons. For suicide, the clinical history always includes an exploration of the means that the patient has been thinking of using to complete the suicidal act.

Where might it occur?

For patients experiencing an acute episode of illness, the risk behaviours may well be more likely to occur whilst they are an inpatient in the psychiatric ward. The risks may be very much less once the patient is discharged. Some depressed patients have an increased risk of suicide at the time of discharge as they re-adapt to the home environment. For other patients, the risk may only occur in an environment where they are triggered; perhaps by seeing someone who reminds them of a previous abuser. For violence, an exploration of situations in which the patient is more likely to be violent will often yield important information.

Towards whom?

Once again this is information which will need to be considered most commonly when the risk is of violence. Often it is family members who are most at risk but for some patients experiencing persecutory delusions, it may well be members of the general public or people from certain racial groups who cannot be identified in advance. In child and adolescent mental health services, the person at risk may be the patient as a result of neglect or abuse from a parent or caregiver.

Safety

Is safety the same as risk? Safety is a word sometimes used synonymously with risk. The dictionary definition, however, is quite different:

Safety: the state of being protected from or guarded against hurt or injury; freedom from danger.

In clinical practice the use of the word safety has connotations of rescuing and taking of responsibility by clinicians. From the definition, safety might be considered to be the opposite of the risk. Serious consideration should be given before the word ‘safety’ is used in everyday practice. Clinicians who use the word ‘safety’ are often anxious about their skills in risk assessment and management or are looking for a shortcut so as not to have to undertake a risk assessment. Here are two common examples of the way the word safety has been used in mental health settings.

1. ‘The patient couldn’t guarantee their safety so I admitted them.’

Nobody can guarantee their safety, never mind a patient with mental illness. This phrase is used less frequently nowadays but when it is used, it is unlikely that an adequate risk assessment will have been completed.

2. ‘The first thing I would like to consider in the management of this patient is the safety issue.’

This is a common phrase used by mental health clinicians which hopefully will become of historical interest only as the difference between risk and safety becomes more overt.

When clinicians engage in ‘safety contracts’ with patients, they enter into a dynamic in which an offer is made to rescue them from their torment and take responsibility. A patient who agrees to a safety contract one day may have a differing mental state the next day and no longer agree to it, but the clinician will assume the agreement is still there.³ ‘Safety contracts’ were used extensively a decade ago, but fortunately have now become rare.

Eliciting guarantees of safety from the patient or developing ‘no self-harm contracts’ are not sufficient as sole management strategies and are not recommended.^4,⁵

BOX 2.2 WHAT IS RISK?

Learning points:

• Risk is the likelihood of an adverse outcome.

• The likelihood of risk changes over time.

• Risk is a part of every decision-making process of patient care.

• Risk involves not just the patient but the patient’s family, the community, mental health staff and the mental health service.

• The use of the word ‘safety’ is not recommended in risk management.

Exercise

Think about the risks that you took today before you started reading this book and why you took them.

For each risk you considered, think about what might have eventuated if you hadn’t taken it. Think about the benefits of taking it.

1 Royal College of Psychiatrists 2008 Rethinking Risk to Others in Mental Health Services. Final report of a scoping group. Royal College of Psychiatrists College Report CR 150, June.

2 Gutheil T.G. Paranoia and progress notes: a guide to forensically informed psychiatric record keeping. Hospital and Community Psychiatry. 1980;31(7):479–482.

3 Bateman A., Fonagy P. Mentalization Based Treatment for Borderline Personality Disorder. Oxford: Oxford University Press; 2006. p 48

4 Boyce P., et al. Summary of Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm. Australasian Psychiatry. 2003;11(2):150–155.

5 Rudd M.D., Mandrusiak M., Joiner T. The case against No-Suicide Contracts: The commitment to treatment statements as a practice alternative. Journal of Clinical Psychology: In Session. 2007;62:243–251.

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